Single Payer Is Not the Answer

We may want, even pray for, a quick, simple, painless answer to big, hard problems. Our brains know that that will never happen. Still, we let our emotions dictate our expectations. So it was with Sarah van Gelder's panegyric for the single-payer solution to healthcare.Her article was filled with errors, magical thinking, and one truth whose implications escaped the author. Van Gelder starts by saying healthcare has been in trouble ever since the Republicans convinced the Obama administration to drop the public option (for health insurance). Recall that in 2008-09, Democrats controlled both Houses of Congress and the White House. Had they wanted the public option in the Reform Bill, it would have been in.

Much more important is the egregious implication that healthcare wasn't in trouble until the Republicans (sic) stopped the magical answer: single-payer. In reality, healthcare has been in deep trouble for over 45 years -- ever since Congress broke open the "lockbox" for our cash contributions to Medicare. They took the money, spent it, and replaced it with IOUs. Ever since then, Medicare has been a Ponzi scheme, one that will collapse by 2017.

One truth in van Gelder's article was the title of the graph: "We're Not Getting Our Money's Worth." Worth is determined by the ratio of how much you expend compared to how much you get of something you want.

The U.S. is indeed spending much more than anyone else on the planet for healthcare (the system) and not getting the results we want from health care (the service). This is true for overall longevity, infant mortality, and for preventable as well as chronic illnesses. The question is, why?

Why are we not getting enough of what we want? Why is the spending excessive? In other words, what are the root causes of the symptom over-spending?

Every good physician, apparently with the exception of van Gelder's "group of 50 doctors," knows that you treat causes of sickness, not the signs and symptoms, regardless of whether the ill patient is a human or a system.

Do you want to cure sick healthcare? Or do you want a quick fix, even though you know that that fix is indeed a colloquial "fix," a palliative? Palliation might make We-The-Patients temporarily feel better, but in reality, it just makes healthcare-the-patient sicker.

You don't cure healthcare's over-spending by spending an additional $1.76 trillion, as does the ACA, or by repeatedly shouting the shibboleth "single-payer."

You cure over-spending by a) defining which spending provides value (and therefore is not "over"), then b) defining which spending does not provide value (and therefore is "over"), and finally c) eliminating as much of (b) as you can.

Some polls show that Americans favor a single-payer system. Others demur. There are three reasons why some may want single-payer. First, healthcare is such a confusing mess that any answer touted as simple, straightforward, and efficient is grasped quickly like a life vest. The fact that single-payer is neither simple nor efficient does not deter our hopeful nature, which leads to the second reason some advocate single-payer: magical thinking. Finally, some ideologues exploit people's trust and continue to advocate single-payer while ignoring the evidence.

Evidence is another requirement for practicing good medicine. What is the hard evidence -- not bombast or fantasy -- about single-payer?

Great Britain has its single-payer NHS (National Health Service). Reeling from spending it cannot afford, the NHS has begun to ration health care. That is what their NICE agency does, and that is what the IPAB (Independent Payment Advisory Board) of the ACA will do here. Single-payer means strict medical rationing by the government. Did van Gelder mention that?

Canada has a single-payer system, which van Gelder likened to our Medicare. Our northern brethren, like Medicare patients here, are literally dying looking for a doctor or waiting in line for care. In Canada, as with Medicare here, payments are so low that doctors cannot see the patients and stay in business.

I especially enjoyed (please take as sardonic) van Gelder's statement that doctors who care for Medicare patients are in "private practice." Private practice connotes rich doctors in their big black Mercedeses, who charge huge fees and make lots of money. Well, doctors can charge whatever they want, but Medicare pays what it pays -- take it or leave it. Before ACA, the payments were so low that doctors could not accept Medicare patients and still make payroll. So what does the ACA do to "save Medicare as we know it"? The ACA cuts Medicare payments to doctors by an additional 21%-27%! Now no provider can afford to see a Medicare patient.

For a single-payer approach closer to home, consider Commonwealth Care (CC) in Massachusetts. Over half of Bay State doctors are leaving or refuse to see patients insured by CC because the payments, just like with Medicare, are below their cost of staying in business. In Massachusetts, a patient covered by CC with a complaint like abdominal pain can wait over six weeks before seeing an internist, family practice physician, or OB-GYN, assuming the patient can even find one.

Never leave them on a low note -- so say the pundits. What might be a high note? My answer is this: we can cure healthcare. Don't sedate, palliate, or mesmerize the patient with single-payer. Don't treat symptoms. Practice good medicine.

The root causes of over-spending are known. Cure the patient by excision -- cut out the cancer of over-spending (and leave the good cells -- the spending we want!).

We may want, even pray for, a quick, simple, painless answer to big, hard problems. Our brains know that that will never happen. Still, we let our emotions dictate our expectations. So it was with Sarah van Gelder's panegyric for the single-payer solution to healthcare.

Her article was filled with errors, magical thinking, and one truth whose implications escaped the author. Van Gelder starts by saying healthcare has been in trouble ever since the Republicans convinced the Obama administration to drop the public option (for health insurance). Recall that in 2008-09, Democrats controlled both Houses of Congress and the White House. Had they wanted the public option in the Reform Bill, it would have been in.

Much more important is the egregious implication that healthcare wasn't in trouble until the Republicans (sic) stopped the magical answer: single-payer. In reality, healthcare has been in deep trouble for over 45 years -- ever since Congress broke open the "lockbox" for our cash contributions to Medicare. They took the money, spent it, and replaced it with IOUs. Ever since then, Medicare has been a Ponzi scheme, one that will collapse by 2017.

One truth in van Gelder's article was the title of the graph: "We're Not Getting Our Money's Worth." Worth is determined by the ratio of how much you expend compared to how much you get of something you want.

The U.S. is indeed spending much more than anyone else on the planet for healthcare (the system) and not getting the results we want from health care (the service). This is true for overall longevity, infant mortality, and for preventable as well as chronic illnesses. The question is, why?

Why are we not getting enough of what we want? Why is the spending excessive? In other words, what are the root causes of the symptom over-spending?

Every good physician, apparently with the exception of van Gelder's "group of 50 doctors," knows that you treat causes of sickness, not the signs and symptoms, regardless of whether the ill patient is a human or a system.

Do you want to cure sick healthcare? Or do you want a quick fix, even though you know that that fix is indeed a colloquial "fix," a palliative? Palliation might make We-The-Patients temporarily feel better, but in reality, it just makes healthcare-the-patient sicker.

You don't cure healthcare's over-spending by spending an additional $1.76 trillion, as does the ACA, or by repeatedly shouting the shibboleth "single-payer."

You cure over-spending by a) defining which spending provides value (and therefore is not "over"), then b) defining which spending does not provide value (and therefore is "over"), and finally c) eliminating as much of (b) as you can.

Some polls show that Americans favor a single-payer system. Others demur. There are three reasons why some may want single-payer. First, healthcare is such a confusing mess that any answer touted as simple, straightforward, and efficient is grasped quickly like a life vest. The fact that single-payer is neither simple nor efficient does not deter our hopeful nature, which leads to the second reason some advocate single-payer: magical thinking. Finally, some ideologues exploit people's trust and continue to advocate single-payer while ignoring the evidence.

Evidence is another requirement for practicing good medicine. What is the hard evidence -- not bombast or fantasy -- about single-payer?

Great Britain has its single-payer NHS (National Health Service). Reeling from spending it cannot afford, the NHS has begun to ration health care. That is what their NICE agency does, and that is what the IPAB (Independent Payment Advisory Board) of the ACA will do here. Single-payer means strict medical rationing by the government. Did van Gelder mention that?

Canada has a single-payer system, which van Gelder likened to our Medicare. Our northern brethren, like Medicare patients here, are literally dying looking for a doctor or waiting in line for care. In Canada, as with Medicare here, payments are so low that doctors cannot see the patients and stay in business.

I especially enjoyed (please take as sardonic) van Gelder's statement that doctors who care for Medicare patients are in "private practice." Private practice connotes rich doctors in their big black Mercedeses, who charge huge fees and make lots of money. Well, doctors can charge whatever they want, but Medicare pays what it pays -- take it or leave it. Before ACA, the payments were so low that doctors could not accept Medicare patients and still make payroll. So what does the ACA do to "save Medicare as we know it"? The ACA cuts Medicare payments to doctors by an additional 21%-27%! Now no provider can afford to see a Medicare patient.

For a single-payer approach closer to home, consider Commonwealth Care (CC) in Massachusetts. Over half of Bay State doctors are leaving or refuse to see patients insured by CC because the payments, just like with Medicare, are below their cost of staying in business. In Massachusetts, a patient covered by CC with a complaint like abdominal pain can wait over six weeks before seeing an internist, family practice physician, or OB-GYN, assuming the patient can even find one.

Never leave them on a low note -- so say the pundits. What might be a high note? My answer is this: we can cure healthcare. Don't sedate, palliate, or mesmerize the patient with single-payer. Don't treat symptoms. Practice good medicine.

The root causes of over-spending are known. Cure the patient by excision -- cut out the cancer of over-spending (and leave the good cells -- the spending we want!).